FORM CCC-934

This form is available electronically
CCC-934
U.S. DEPARTMENT OF AGRICULTURE
Commodity Credit Corporation
(04-1~14)
EMERGENCY LOSS ASSISTANCE FOR
HONEYBEES I FARM-RAISED FISH APPLICATION
I NOTE:
1. State and County Code
2. Program Year
3. County Office Name
4. Application Number
""'1
tne TOllowmg s a emen IS meae tn eccoraence wnn me nvacy ...c a
I_" u,:,,, """a
as amenue~J. t ne eutnonty Tor reques mg me tntotmeuon toentmea on
this form is 7 CFR Part 1416. the Commodity Credit Corporation Charter Act (15 U.S.C. 714 et seq.), and the Agricultural Act of 2014 (Pub. L. 113-79).
The
Information will be used to determine eligibility for emergency loss assistance program benefits. The information col/ected on tlls form may be disclosed to otheT
Federal, State, Local government agencies, Tribal agencies, and nongovernmental entities that have been authorized access to the information by statute or regulation
and/or as described in applicable Routine Uses identified in the System of Records Notice for USOAlFSA-2, Farm Records File (Automated). Providing the requested
Information is voluntary. However, failure to furnish the requested information will result in a determination of Ineligibility for emergency loss as sistance program
benefits.
This information col/ection is exempted from the Paperwork Reduction Act as it is required for the administration of the Agricultural Act of 2014 (Pub. L. 113-79).
The provisions of criminal and civil fraud, privacy and other statutes may be applicable to the information provided.
COUNTY FSA OFFICE.
RETURN THIS COMPLETED
FORM TO YOU"
PART A - PRODUCER INFORMATION
5A. Producer's Name and Address (City, State and Zip Code)
D Honeybee Colony Loss (Part
C)
D Farm-Raised Fish Death Loss (Part D)
D Value of Purchased Feed Lost and/or Additional
D Additional Feed Purchased Above Normal-
D Honeybee Hive Loss (Part E)
Expenses- Honeybees and Farm-Raised Fish (Part F)
HI'I""vI'I ..,."
Qualifying Weather or Loss Condition
Date When
Loss Occurred
Physical Location County of Loss
Loss
rent
Loss Event 1
Loss Event 2
Loss Event 3
I
farm-raisedflsh in inventory? (/rr:/ude County name, fann
Loss Event 1
Loss Event 2
Loss Event 3
share of any honeybee
9A. Producer's
9C. Date (MM-DD- YYYY)
Representative Capacity
Adjusted
Beginning
I
Adjusted Ending
Inventory
Adjusted
Ineligible
Inventory Lost
Honeybee
Hives Lost
Hives Lost
Indicate Honeybees (H) or
Farm-Raised Fish (F)
F eed/Expense
(H or F)
Number
Years Prior
Ineligible Hives
Lost
and/or farm-raised fish due to losses from adverse weather or loss conditions as determined by the Secretary.
CCC-934 to be eligible to receive program benefits. By signing this application, the producer or producers:
1. Agrees to provide CCC any documentation it requires to determine eligibility that verifies and supports all information provided, including the
producer's certification, and understands the application may be disapproved if they fail to provide. any such information requested by CCC;
2. Authorizes CCC, at any time, with or with~ut their presence, to enter upon, inspect and verify all honeybee colonies, honeybee hives, farm-raised
fish, ponds, and acres in which they have an interest;
3. Agrees to comply with, and acknowledges they and their application are subject to, all the regulations governing the program and understands that
instructions and assistance are available for completing this form; and,
4. Authorizes CCC to obtain from third parties, such as, but not limited to, other government agencies, individuals, suppliers, contractors, or
processors, feed cooperatives, and feed supply companies, any records or other evidence that substantiates the information provided on this
application or any supporting documentation provided.
certify that:
I. Ifapplying as an individual, that I am a citizen of the United States or a resident alien; ifapplying as a partnership, the members of the partnership
are citizens of the United States;_or if applying as a corporation, limited liability corporation, or other farm organizational structure, the entity is
organized under State law; if applying as a Native American tribe, the tribe is organized according to the Indian Self-Determination and Education
Assistance Act; if applying as any Native American organization or entity, the Native American organization or entity is chartered under the Indian
Reorganization Act; if applying as a Native American economic enterprise, the enterprise was established under the Indian Financing Act of 1914.
2. On the beginning date of the adverse weather or loss condition(s) in Item 7, I owned all honeybee colonies, honeybee hives, and/or farm
raised fish entered on this application and physically maintained control of all such honeybees and/or farm-raised fish on that date for commercia]
use as part of my farming operation;
3. All honeybee colonies, honeybee hives, and/or farm-raised fish entered as lost on this application and/or additional feed expenses were losses
incurred as a direct result of a qualifying adverse weather or loss condition(s) entered in Item 7 that occurred in the county provided in Item 3.
4. All information on this application and all supporting documents I provided are true and correct;
5. ] understand that this application may be disapproved if information or evidence provided is false or in error, and that other sanctions or penalties
could apply.
o Approved
The U.S. Department of Agriculture (USDA) prohibits discrimination agains( its customers, employees, and applicants for empto/men: on the basis of
race, color, national origin, age, disability, sex, gender identity, religion, reprisal, and where applicable, political beliefs, marital status, familial or parental
status, sexual orientation, or all or part of an individual'S income is derived from any public assistance program, or protected genetic information in
employment or in any program or activity conducted or funded by the Department. (Not all prohibited bas is will apply to aI/ programs and/or employment
activities.) Persons with disabilities, who wish to file a program complaint, write to the 'eaaress below or if you require citemative means of
communication for program information (e.g., Braille, large prirt, audiotape, etc.) please contact USDA's TARGET Center at (202) 720-2600 (voice and
TOO). Individuals who are deaf. hard of hearing, or have speech disabilities and wish to file either an EEO or program compl aint, please contact USDA
through the Federal Relay Service at (800) 877-8339 or (800) 845-6136 (in Spanish).
If you wish to file a Civil Rights program complaint of discrimination, complete the USDA Program Discrimination Complaint Form, found online at
http://www.ascr.usda.gov/complaintJiling_custhtml,
or at any USDA office, or call (866) 632-9992 to request the form. You may also write a letter
containing all of the information requested in the form. Send your completed complaint form or letter by mail to U.S. Department of Agriculture, Director,
Office of Adjudication, 1400 Independence Avenue, S. W, Washington, D. C. 20250.9410, by fax (202) 690. 7442 or email at
[email protected].
USDA is an equal opportunity provider and employer.
---
--------------
This form is available
electronicall
CCC-934-A
.
1. State and County Code
2. Program Year
3. County Office Name
4. Application N~mber
U.S. DEPARTMENT OF AGRICULTURE
Commodity Credit Corporation
(04-15-14)
CONTINUATION SHEET FOR EMERGENCY LOSS
ASSISTANCE FOR HONEYBEES/FARM-RAISED FISH
APPLICATION
e 0 oWing s a emen IS ma e In acco ance WI
e nvacy c 0
a - as amen e
e au on
or reques ng e In rma IOn I en 1 e on IS
form Is 7 CFR Part 1416, the Commodity Credit Corporation Charter Act (15 U.S.C. 714 et seq.), and the Agricultural Act of 2014 (Pub. L. 113-79). The information will
be used to determine eligibility for emergency loss assistance program benefits. The information collected on this form may be disclosed to other Federal, State, Local
government agencies, Tribal agencies, and nongovernmental entities that have been authorized access to the information by statute or regulation and/or as described
in applicable Routine Uses ideritified in the System of Records Notice for USDAlFSA-2, Farm Records File (Automated).
Providing the requested information is
voluntary. However, failure to furnish the requested information will result In a determination of ineligibility for emergency loss assistance program benefits.
This Information collection is exempted from the Paperwork Reduction Act as specified in the Agricultural Act of 2014 (Pub. L 113-79, Title I. Subtitle F, Administration).
The provisions of criminal and civil fraud, privacy and other statutes may be applicable
COUNTY FSA OFFICE.
PART C - HONEYBEE
'1::
Loss Event
Number
COLONY
Additions to
Inventory
Throughout
Program Year
Reductions to Total Number of
Inventory
Honeybee
Throughout
Colonies Lost
Program Year
During the
Program Year
FISH DEATH
PART E - HONEYBEE
.:
Inventory at
Beginning of
Program Year
Unit of
Measure
Ineligible
Honeybee
Colonies Lost
During the
Program Year
Producer
Share
COC Use Only
I.<r.
Adjusted
Beginning
Inventory
l~J.
1~1.
Adjusted
Adjusted
Additions to Reductions to
Inventory
Inventory
1~1\.
lLL.
Adjusted
Number of
Lost
Colonies
Adjusted
Number of
Ineligible
Colonies
Lost
LOSS (Continuation)
: g
Inventory
I
Type/Kind/Slze
FORM TO YOUR
LOSS (Continuation)
:
.".
Loss Event
Number
RETURN THIS COMPLETED
I
Inventory at
Beginning of
Program Year
PART D - FARM-RAISED
Loss Event
Number(s)
to the information provided.
g
Ending
Inventory
Ineligible
Inventory Lost
Producer
Share
COC Use Only
13H.
Adjusted
Beginning
Inventory
131.
Adjusted Ending
Inventory
13J.
Adjusted
Ineligible
Inventory Lost
HIVE LOSS (Continuation)
Additions to
Inventory
.•
Reductions to
Inventory
,.,
----------- -----------
•
Number of
Honeybee
Hives Lost
Ineligible
Honey Bee
Hives Lost
Producer
Share
14r.
Adjusted
Beginning
Inventory
141.
I
14J.
Adjusted
Adjusted
Additions to Reductions
Inventory
to Inventory
• ~ •
141\.
14L.
Adjusted
Number of
Hives Lost
Adjusted
Number of
Ineligible Hives
Lost
CCC·934·A (04-15-14)
IPART F - VALUE OF PURCHASED
FEED LOST ANDIOR ADDITIONAL EXPENSES _ HONEYBEES AND FARM-RAISED
(Continuation)
Loss Event
Number
:
Indicate Honeybees (H) or
Farm-Raised Fish (F)
Feed/Expense
(H or F)
•
Type of Feed Lost or Addttional
Expense Incurred
Value of Feed Lost or
Addttional Expense Incurred
•
Loss
Event
Number
'
-
$
$
$
$
$
$
$
$
$
$
$
$
$
, ,
$
..
..
I
ior-.
Adjusted Value of Feed Lost or
Addttional Expense Incurred
Producer
Share
$
PART G - ADDITIONAL
Page 2 of2
FISH
$
$
$
..
FEED PURCHASED ABOVE NORMAL - HONEYBEES (Continuation)
"
Type of Addttional Feed
Purchased Above Normal
Cost of Feed
Purchased in
Application Year
.
Cost of Feed
Purchased 2
Years Prior
Cost of Feed
Purchased 1 Year
Prior
Producer
Share
COCUse 0 n,y
I
16Gc
Adjusted Cost of
Feed Purchased in
Application Year
Adjusted Cost of
Feed Purchased
1 Year Prior
16H.
161.
Adjusted Cost of Feed
Purchased in 2 Years Prior
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
,
\
The U.S. Department of Agriculture (USDA) prohibits discrimination against its customers, employees, and applicants for employment on the basis of
race, color, national origin, age, disability, sex, gender identity, religion, reprisal, and where applicable, political beliefs, marital status, familial or parental
status, sexual orientation, or all or part of an individual's income is derived from any public assistance program, or protec ted genetic information in
employment or in any program or activity conducted or funded by the Department. (Not all prohibited bas is will apply to all programs and/or employment
activities.) Persons with disabiliues, who wish to file a program complaint, write to the address below or if you require citemative means of
communication for program irformation (e.g., Braille, large print, audiotape, etc.) please contact USDA's TARGET Center at (202) 720-2600 (voice and
TOD). Individuals who are deaf, hard of hearing, or have speech disabilities and wish to file either an EEO or program compl aint, please contact USDA
through the Federal Relay SeNice at (800) 877-8339 or (800) 84~6136 (in Spanish).
If you wish to file a Civil Rights program complaint of discrimination, complete the USDA Program Discrimination Complaint Form, found online at
http://www.ascr.usda.gov/compfaint_filing_cust.htmf,
or at any USDA office, or call (866) 632-9992 to request the form. You may also write a letter
containing all of the information requested in the form. Send your completed complaint form or letter by mail to U.S. Department of Agriculture, Director,
Office of Adjudication, 1400 Independence Avenue, S. W, Washington, D.C. 202S()'9410, by fax (202) 69()'7442 or email at
[email protected].
USDA is an equal opportunity provider and employer.

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